Selective serotonin reuptake inhibitor antidepressants: cardiovascular complications--sorting through findings

The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review

CONTEXT

Although panic disorder is linked to hypertension and smoking, the relationship between panic disorder and coronary artery disease (CAD) is unclear.

OBJECTIVE

To extend our understanding about the strength of the association between panic disorder and coronary artery disease and known cardiovascular risk factors.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM-IV criteria, and studies must have used objective criteria for CAD and risk factors. Only case-control and cohort studies were included.

DATA SYNTHESIS

Concerning the relationship between panic disorder and CAD, studies conducted in emergency departments found a relative risk [RR] of 1.25 (95% CI = 0.87 to 1.80), while those conducted in cardiology settings found an inverse relationship (RR = 0.19, 95% CI = 0.10 to 0.37). However, there is an inverse relationship between the prevalence of CAD in the study and the RR (r = -.554, p = .097), suggesting that, in primary care settings in which the prevalence of CAD is low, there may be a significant association between panic disorder and CAD.

CONCLUSION

The association between panic disorder and CAD has several implications for primary care physicians managing patients with chest pain. When comorbid, the panic attacks may cause the patient with coronary disease to seek care but could also provoke a cardiac event. If one condition is recognized, a search for the other may be warranted because of the potential consequences if left undetected. The treatment approach to the panic disorder should be adjusted in the presence of comorbid CAD.

Effect of selective serotonin reuptake inhibitors on platelet activation: can they prevent acute myocardial infarction?

In recent years a large body of evidence from several longitudinal studies has emerged suggesting that depression is an independent risk factor for cardiovascular disease (CVD) and that the association between depression and increased CVD risk is not merely due to negative mood-driven behavior related with depression. Even though the underlying mechanisms are not well understood, several hypotheses and explanations have been proposed such as increased activation of the hypothalamic-pituitary-adrenal axis, abnormalities in the sympathoadrenal system, or abnormalities in platelet function. Platelet function abnormalities, including increased platelet reactivity, may predispose patients with depressive disorders to clotting diatheses and may explain their vulnerability to CVD. Serotonin secreted by platelets induces both platelet aggregation and coronary vasoconstriction. Even though serotonin itself is only a weak platelet agonist, it markedly enhances platelet reactions to a variety of other agonists. Several studies have shown that selective serotonin reuptake inhibitors (SSRIs) reduce platelet and whole blood serotonin concentrations after repeated doses, and could therefore exert an inhibitory effect on platelet activation. For that reason, it was hypothesized that SSRIs could have a protective effect against myocardial infarction (MI). Results from three currently available epidemiological studies assessing the risk of MI in patients treated with antidepressants, including SSRIs, are controversial with respect to a potential beneficial effect of SSRIs on CVD risk in depressed patients. However, there is evidence that exposure to SSRIs does not substantially increase the risk of CVD in patients. A recent randomized, double-blind, placebo-controlled, multicenter trial that evaluated the safety and efficacy of the SSRI sertraline in patients with major depression and acute MI or unstable angina suggested that sertraline is well tolerated and effective. Further epidemiological studies or longer-term clinical trials may shed more light on this issue, and answer the question conclusively, whether the effect of SSRIs on platelets or another mechanism translates into a decreased risk of CVD in depressed patients.